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1 1. introduction Few seek psychiatric intervention even during crisis Usually seek by parents, relatives, teachers, therapists, physicians, and child.

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Presentation on theme: "1 1. introduction Few seek psychiatric intervention even during crisis Usually seek by parents, relatives, teachers, therapists, physicians, and child."— Presentation transcript:

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2 introduction Few seek psychiatric intervention even during crisis Usually seek by parents, relatives, teachers, therapists, physicians, and child protective service workers. ya2

3 classification life-threatening referrals Non life-threatening referrals 3

4 Life-Threatening Emergencies Suicidal behavior Homicidal behavior Violent Behavior and Tantrums Fire setting Child Abuse: Physical and Sexual Neglect: Failure to Thrive Anorexia nervosa Acquired Immune Deficiency Syndrome 4

5 Non-Life-Threatening Situations School refusal Posttraumatic Stress Disorder Dissociative disorder 5

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7 Introduction Depression as the most significant psychiatric risk factor Majority of depressed individuals neither complete nor attempt suicide No mood disorder in many children and adolescents engaged in suicidal behavior 7

8 Definition Suicidal behavior is a spectrum passive thoughts of death (e.g., May be I would be better off dead) active suicidal ideation (e.g., I would like to kill myself) suicidal ideation with a plan and intent Suicidal threats (verbalization of suicidal ideation) m8

9 definition Self-injurious behavior( relief of painful affect) suicidal attempt (self-destructive behavior with inferred or explicit intent to die) Completed suicide ( suicide attempt results in death) 9

10 Epidemiology 3-month prevalence study in 9- to 16-year- olds Wanting to die of around 1 percent Ideation with a plan of 0.3 percent Suicide attempt of 0.25 percent. 10

11 Epidemiology In a study on 14- to 18-year-olds The lifetime prevalence of suicide attempts was 7.1 percent rates for girls (10.1 percent) rates for boys (3.8 percent) The annual suicide attempt rate for medically serious suicide attempts in adolescents (1 to 2 percent) 11

12 Completed suicide 10-14 years olds 0.95/100,000 for female 1.71/100,000, respectively, for male 15-19 years olds 3.52/100,000 for female 12.65/100,000 for male m12

13 Epidemiology The rate of suicidal behavior increase with age The most common method for adolescent suicide attempts is overdose, with the second-most-common method being wrist cutting The most common method in the United States for completed suicide is using firearms, followed by hanging, jumping, carbon monoxide poisoning, and taking an overdose. yassiniard@yahoo.com13

14 Risk factors Intensity and intent lethality precipitant motivation availability of lethal agents. com14

15 Intensity and Intent In adolescent suicide attempt chance of a reattempt within 1 year is 15-30% highest risk for reattempt is the first 3 months In suicide attempters risk for completed suicide is 10-60 folds highest risk in attempts of high lethality and intent 15

16 motivation key to an effective treatment plan Wish to die in one third of adolescents who attempt suicide Escape an intolerable situation, express hostility, or get attention and support in remainder 16

17 Precipitant Most common precipitants for suicidal behavior are: Parent–child conflict In younger children and adolescents Difficulties in peer and romantic relationships In older adolescents 17

18 Lethality Lethality refers to the medical dangerousness of the suicide attempt. Intent and lethality are not always highly correlated, especially in children and young adolescents (gesture, impulsive attempts) Attempts resemble completers are much more likely eventually to complete suicide with regard to method (hanging or firearms) 18

19 Availability of Lethal Agents In USA approximately 60 percent of youth suicides involve firearms Hanging is the leading cause of death in many other countries. An association between the availability of guns, particularly handguns, and risk for completed suicide Other cultural factors governing method choice.( low firearm-related suicide rate in Switzerland in spite of gun availability) 19

20 Etiology Mental disorder Suicide in the Apparent Absence of Disorder Health Risk Behaviors Medical conditions Familial and Environmental Factors Psychological factors Exposure to Suicidal Behavior Biological factors 20

21 Mental Disorder The rate of psychiatric disorder in completed and attempted suicide is 90 and 80 percent respectively. Greater chronicity, severity, and complexity (e.g., comorbidity) and more suicidal behavior 21

22 Mental disorder Mood disorders are strongly associated with more suicidal behavior 60 percent of adolescent suicide victims had a mood disorder at the time of death. High risk of suicidal attempts and completions in BMD(rapid cycling or a mixed state ) More insomnia, agitation, and irritability more suicidal behavior 22

23 Suicide in the Apparent Absence of Disorder No clear evidence for psychiatric disorder in 40% of young adolescents in 90% of old adolescents The most common contributory factors are: disciplinary precipitant an impulsive suicide attempt the presence of a loaded gun in the home 23

24 Health Risk Behaviors Suicidal behavior most commonly occurs as part of a constellation of other health risk behaviors Non suicidal self-injurious behavior Binge drinking Abnormal eating behavior Weapon carrying Unprotected sex 24

25 risk factors for health risk behaviors Weak parent–child relationship Conflict in parent–child relationship poor connection between child and school association with deviant peers. 25

26 Medical Conditions chronic illnesses such as epilepsy, diabetes, and asthma increase risk for depression and suicidal behavior Poor physical health and disability has also been associated with suicidal behavior 26

27 Psychological Factors Impulsive aggression Neuroticism Hopelessness or pessimism Same-sex attraction 27

28 Familial and Environmental Factors Higher rates of depression, substance abuse, and assaultive behavior in the parents of adolescent suicide attempters and completers loss of a parent before the age of 12 years associated with an increased risk of recurrent suicidal behavior. Attempted suicide among family and friends related to an increased risk of attempt in adolescents 28

29 Familial and Environmental Factors Child suicide attempt associated with Parent–child discord perceived lack of support High levels of criticism and hostility 29

30 Familial and Environmental Factors Physical and sexual abuse and neglect as the most clinically significant family risk factor for suicidal behavior Youth at risk for suicidal behavior are not well connected to school, work, or family m30

31 Biological factors The associations of altered central serotonin with suicidal behavior and impulsive aggression Altered central serotonergic function in adverse family environment, such as early separation, discord, socioeconomic stress, and abuse Biological factor may result from both genetic and environmental predispositions. 31

32 Course and Prognosis Suicidal behavior is highly recurrent. 15 to 30% of adolescents reattempt suicide with 1 year 0.5-1% per year is the risk for a completed suicide High proportion of individuals with suicidal ideation with a plan go on to make an attempt within 1 year. 32

33 Predictors of reattempt Severity of depression Continued suicidal ideation Comorbid anxiety and conduct disorder Impulsive aggressive personality traits, Hopelessness Family discord History of sexual abuse. 33

34 Treatment Suicidal ideation is highly correlated with the severity of depression Concomitant decrease in suicidal ideation along with reduction in depression A decline in the suicide rate that coincides with increased prescriptions for SSRIs. 34

35 Treatment No definitive psychosocial or pharmacological treatments for suicidal behavior. Treating the related psychiatric disorder and psychosocial difficulties, such as family discord and difficulties with emotion regulation and problem solving A safty plan to avoid precipitants for recurrent suicidal behavior and to cope with suicidal ideation if it reoccurs. 35

36 Treatment lithium may be efficacious in individuals with bipolar, and even unipolar, depression. Emotion regulation and problem solving Brief cognitive–behavioral therapy Improving the detection and treatment of depression in primary care 36

37 TreatmenT,Current guidelines Removing or securing lethal agents from the home Treating the underlying psychiatric disorders Addressing the psychosocial issues, such as hopelessness, family discord, poor emotional regulation skills, or impaired social problem solving 37

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39 Assessment Make sure that both the child and the staff members are physically protected physical restraint may be necessary before anything else is attempted Most likely to calm down if approached calmly in a nonthreatening manner and given a chance to tell their side of the story to a nonjudgmental adult looking for any underlying psychiatric disorder 39

40 Management Prepubertal children, in the absence of major psychiatric illness, rarely require medication to keep them safe, because they are generally small enough to be physically restrained if they begin to hurt themselves or others. It is not immediately necessary to administer medication to a child or an adolescent who was in a rage but is in a calm state when examined. 40

41 management Medication before a dialogue if adolescents and older children are assaultive, extremely agitated, or overtly self-injurious No hospitalzation need if they are able to calm down during the course of the evaluation. Hospitalization is necessary if adolescents continue to pose a danger to themselves or others during the evaluation period 41

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43 Assessment Physical and sexual abuse occurs in girls and boys of all ages, in all ethnic groups, and at all socioeconomic levels. The abuses vary widely with respect to severity and duration, but any form of continued abuse constitutes an emergency situation for a child fear, guilt, anxiety, depression, and ambivalence regarding disclosure commonly surrounds the child who has been abused. 43

44 Assessment The child and other family members must be interviewed individually to give each member a chance to speak privately. If possible, the clinician should observe the child with each parent individually to get a sense of the spontaneity, warmth, fear, anxiety, or other prominent features of the relationships. One observation is generally not sufficient to make a final judgment about the family relationship 44

45 Physical indicators of sexual abuse sexually transmitted diseases (e.g., gonorrhea) pain, irritation, and itching of the genitalia and the urinary tract discomfort while sitting and walking. In many instances of suspected sexual abuse, however, physical evidence is not present. Thus, a careful history is essential. m45

46 m46

47 Assessment May occur in a young child who is first entering school or in an older child or adolescent who is making a transition into a new grade or school, or without an obvious external stressor. In any case, school refusal requires immediate intervention, because the longer the dysfunctional pattern continues, the more difficult it is to interrupt. 47

48 Assessment School refusal is generally associated with separation anxiety. Severe psychopathology, including anxiety and depressive disorders, is often present when school refusal occurs for the first time in an adolescent. Extreme worries that catastrophic events will befall their mothers, attachment figures, or themselves as a result of the separation. Somatic complaints such as headaches, stomachaches, and nausea. The stated reasons for refusing to go to school are often physical complaints. om 48

49 Management In severe cases, however, a multidimensional, long- term family-oriented treatment plan is necessary Whenever possible, a separation-anxious child should be brought back to school When the child's anxiety is not diminished by behavioral methods alone, tricyclic antidepressants, such as imipramine (Tofranil), are helpful. 49

50 yassiniard@yahoo.com50

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